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The Clinical Practice Evaluation Programme

In 1997 the Clinical Practice Evaluation Programme (CPEP) was established by the RCGP as part of its quality initiative.

This article describes the progress of CPEP, how it fits with the NHS quality agenda and how it provides support to general practice teams on effective clinical practice in the care of people with coronary heart disease (CHD), asthma, diabetes and depression.

clinical practice evaluation programme

Set up

Mid-1998

Objectives

To develop and disseminate evidence-based review criteria for important conditions managed in primary care and to investigate methods by which relevant and useful information can be collected and compared in clinical practice

Funding

National Institute for Clinical Excellence and an educational grant from Merck Sharp & Dohme

As experience with multidisciplinary clinical audit gathered in general practice it became clear that a lot of energy was being expended by local teams in developing evidence-based audit tools. Many of the materials were relatively similar, and all required substantial financial and skills resource to find the evidence or the guidelines to support the development of the materials.

Additionally, although in some areas it was becoming possible to compare the quality of care between practice teams, there was no national general practice programme that could both provide common, evidence-based audit criteria and link this with a comparative audit results feedback system.

So CPEP was set up as a feasibility study to:

Develop evidence-based (audit) review criteria for important common conditions managed in primary care

Explore methods for setting up systems of data capture and feedback of audit based on the standardised review criteria

Implement a first phase of the programme nationally

Evaluate whether the approach was feasible over the long term

Looking at the original documents written in early 1997 brought home how much the NHS has changed in the past 3 years, and how CPEP has had to move with those changes.

No mention of primary care groups/ trusts (PCG/Ts) in those early documents, or their equivalents in Scotland, Wales and Northern Ireland, or how fast the four health services would develop their own identities. No mention of National Service Frameworks (NSFs), although early indications were there in the national health strategy, and no mention either of the National Institute for Clinical Excellence (NICE).

Yet all of these issues are critical to the way that CPEP now works, and have had important effects on the feasibility phase of CPEP.

The delay in getting financial support for a project such as CPEP can often be frustrating, but on this occasion the lead time to start up has played into our hands.

With a generous educational grant from Merck Sharp & Dohme, and support from the DoH audit programme (and now NICE), we got started in mid-1998. By this time some of the NHS changes were emerging, so we were able to take them into account in our 2-year programme of work, which has three main themes:

Exploring where CPEP could give the best value in a rapidly changing NHS

CPEP is designed for use by all general practice teams, whatever their stage of development.

I have not used the term evidence-based medicine here because I believe it frames the scope too narrowly. For example, evidence-based nursing practice is integral to effective general practice care and not all good quality primary care has the evidence base to support it.

Most of the changes that have taken place around us have provided opportunities to support effective general practice and caring for patients (provided that the skills of the good primary care audit groups haven't been lost in the excitement, because we need those partnerships).

Three of the four clinical topics that we chose almost 4 years ago are now part of national priorities through the NSFs, and asthma is an obvious fourth choice.

With the organisation of general practice into local groupings or trusts, and the focus on quality as a key part of clinical governance, the time is ripe to produce materials to support effective practice by general practice teams.

The principles we use to develop review criteria are covered in detail in the editorial, citing stable angina as an example.

Not surprisingly, our investigation of the opportunities for providing national feedback systems has proved something of a curate's egg. Examples of good practice exist in many areas, often using templates on practice computer systems, or through projects using the MIQUEST system, or as a product of Eollecting information on prescribing for commercial organisations.

But problems remain with clinical coding systems and with the quality of data captured, and the CPEP project team continues to work with colleagues in a number of projects to define ways foward when we report later this year.

In the short term the CPEP team will produce review criteria on asthma, Type 2 diabetes and depression by October 2000.

Whether there is a future for the project, for instance in developing new sets of criteria or, just as importantly, keeping criteria up to date, remains unclear until policy issues (do we want it?) and practical issues (how can it be funded?) are answered. Meanwhile, if interest remains as high as it has so far, we will have our hands full.

Home page of the CPEP website

This article has been written on behalf of the CPEP team at the University of Sheffield  Aileen McIntosh, Jeff Anderson, Claire Gilbert and Rosemary Field, and Paula-Jayne McDowell at the RCGP in London.